Continuum of Care
Problem Identification: Motivation & solution generation
Subtopic: Health services and patient transfer linkages
Prepared by Chishimba, Mike, and Sam
Challenge: Confluent medical records
Motivation
At the moment, there are few linkages among the parties involved in providing healthcare
[in Zambia]. The parties involved may include home-based care, government clinics, and
hospices. Once of the most important links among the parties in communication of
patient medical records. These records are an essential component in monitoring patient
information (i.e. clinical progression, medication regimens, diagnostic tests) when the
patient is shifted from one level of care provider to another. There is, often times,
reference to a patient’s medical history during these transfers, in order for the patient to
get proper attentions from their receiving healthcare provider, but the information is
incomplete.
Medical records, if available to home-based care, government clinics, and
hospices in correct and sufficient ways can help link the three individual pieces and help
minimize the burden of finding out about patients history in that all the records would be
readily available.
Potential solutions
The most important thing to consider when trying to solve the non-flow of patient
information among all the pieces involved in healthcare [home-based care, hospices, and
government clinics in Lusaka] is finding a way of keeping records that can be accessible
to all the individual pieces. This can be accomplished by having a central
location/database for depositing and accessing medical records by each entity or each
facility maintaining their own database in which other entities have access. A mutually
accessible database that can be updated by all entities should thus be a part of the link. In
either case, a reference [i.e. unique patient identifier] will need to be made for each
patient that is consistent among healthcare providers that is to be used for storing patient
data and during referrals.
Challenge: Furthering education of healthcare providers
Current education of community health providers (i.e. clinical officers, community
nurses, and home-based care workers) is done by different groups. Clinical officers and
community nurses graduate from the University of Zambia clinical officer program and
Nursing College of Zambia, respectively, while home-based care workers are typically
trained by NGOs.
The whole aspect of education in home-based care has problems which have made the
programs less than efficient. If this gap in education could be addressed, the delivery of
community healthcare could be improved. Some of the problems/challenges in homebased care education programs include the following:
1
Home-based care workers are not trained by or supervised by government clinics and/or
hospices.
The whole concept of home-based care originates from the community and not the
government clinics. Whole clinics and hospices could be controlled with the formulation
of education modules. Currently they are not an integral part of HBC worker training.
The result of this is that most government clinics do not recognize HBC workers as
trained enough to carry out basic healthcare. This not only slows or impairs referrals, but
also blocks information passage between healthcare institutions. Instead of being
complimentary, this lack of transparency does not allow the institutions to work together.
Another complication that arises due to fewer interaction between hospices and
clinics in training of home-based care workers is that this interaction is important for the
healthcare provider-patient relationship. Home-based care workers become more integral
in educating patients, compared to other healthcare providers, because of time constraints
for the latter. Because home-based care workers are not educated by the government
clinics or hospices, they can not educate patients properly once they are discharged (i.e.
medication strategy). Specifically, this includes the education of HIV/AIDS patients on
ARV adherence.
This lack of educational collaboration between government clinics and homebased care workers also limits the depth of education/prevention strategies for
community-borne diseases such as Cholera and TB because a large proportion of homebased care programs tend to specialize in HIV/AIDS.
Home-based care workers typically lack the clinical know how required to effectively
interface with hospices and clinics.
Home-based care workers cold better alter clinics and hospices if they had a better
understanding of clinical parameters/signs to look for and communicate on. Improving
home-based care worker education would allow the worker to provide more supportive
information to care centers on the specific illness and patient history during referrals.
Education will also help address the problem of adherence as home-based care workers
better understand the clinical implications of non-adherence and strategies for promoting
adherence.
Possible solutions
From the beginning of training, government clinics and hospices need to be involved with
the recruitment and training of home-based care workers. That way they could dictate
the clinical criteria and basic requirements for training. This can be in the form of
guidance/recommendations on training or direct training, but a plan should also be made
for periodic refresher or advancement courses.
2
Challenge: Referral system between health centers and home-based care
Motivation
The home-based care institutions should not be recruiting patients on their own,
but rather should have patients referred to them. Currently, however, there are ineffective
referral systems existing between government institutions (clinics) and HBC institutions.
One challenge has been for HBC institutes to have adequate capacity by HBC institutes
to cope with community referrals (self or family) even without government clinic
referrals. Also, there seems to be no formal channels by which government clinics can
refer patients who require HBC and this task is largely left to the family, community and
faith-based organizations (e.g. churches). The government health institutions are ideally
supposed to have social workers (social welfare department) to provide support for and
cater to patients’ social requirements; in some health centers where these exist, they try to
form a link between government institutions and health centers. However, their services
are generally inadequate, as they are poorly funded and staffed; they also have an unclear
relationship (referral-wise) with the HBC centers. This sometimes leaves patients
requiring HBC services stranded in government institutions.
[It should be noted that, although these deficiencies are common, some
institutions have worked to create for themselves some of the structures that are lacking
as a national policy. On various levels, and with various efficiencies and success, health
centers do communicate HBC centers with referrals. For example, Kalingalinga Clinic, a
government clinic in Lusaka, referrals are given to the Kalingalinga Home-Based Care
program. These referrals are given for one of three reasons: 1) A new ARV patient; 2)
Patients who are not getting the right nutrition and need nutrition assistance; 3) Patients
who are on the "Let list", (e.g. those who do not pick up their drugs at appointed time).
The referral consists of a patient name and patient file #; the HBC workers then must
come to Kalingalinga clinic and look up the patient records, using the file number. The
records are paper, and they are not photo copied or given to the HBC worker; information
taken from the records must be manually copied. In practice, the HBC workers do take
advantage of the availability of health records, and they usually make the trip to the clinic
to look up the files of the patients and write down the important information.]
This problem needs to be addressed because the plight of the patients is at stake
and there should be more effective utilization of resources, both at health center level,
HBC level, and community level. Further, because of a lack of well-defined referral
procedures, health care workers are unable to direct needy patients who would clearly
benefit from HBC services. Again, this gap is not because such services do not exist, but
because they do not know of procedures or such to establish the linkage. If there was a
good referral system, HBC institutions would need expanded capacity to deal with
government healthcare patients referred to them; they are often already overwhelmed by
patients brought in by family or community members. (The capacity needs would be in
terms of bed space and the human resources needed to run these HBC centers.) Solving
the referral communication deficiency would effectively lead to better utilization of
resources, as patients requiring HBC services would easily be referred to HBC and free
up bed space and nursing demands in the already over-crowded and understaffed
government centers.
3
Possible solutions
The first approach to finding a meaningful solution to the above problem is to identify
and acknowledge that there are serious problems in the current system and that things
could be better if we choose to make the system better. Therefore, the policy makers
need to clearly outline a policy that defines the referral relationship between all HBC
institutions and government centers. This must be made known to all staff, and all should
clearly understand how to recommend such patients. Further, since HBCs don’t have
sufficient capacity to handle all patients in the case of an effective referral system,
incentives and support should given to all HBC services and provisions should be made
to enable them to improve and expand their services.
4
MIT OpenCourseWare
http://ocw.mit.edu
EC.S11 Engineering Capacity in Community-Based Healthcare
Fall 2005
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